While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?
Monitor I&O
Check blood pressure
Assess pain level
Measure oxygen saturation
The Correct Answer is B
A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Chronic and excessive alcohol consumption is a well-established risk factor for the development of chronic pancreatitis.
B) While contributing to other health issues, it is not directly linked to chronic pancreatitis.
C) Smoking is a risk factor, but alcohol abuse is more significantly associated with chronic pancreatitis.
D) Although it contributes to various health problems, it is not as directly linked to chronic pancreatitis as alcohol abuse.
Correct Answer is ["A","B","C"]
Explanation
A) PT is prolonged in cirrhosis due to impaired synthesis of clotting factors by the liver, making it important to monitor for bleeding risk.
B) Serum albumin levels decrease in cirrhosis due to impaired liver function, reflecting the client's nutritional status and liver synthetic function.
C) Elevated serum ammonia levels can indicate hepatic encephalopathy, a complication of cirrhosis characterized by altered mental status.
D) Troponin is not typically evaluated in cirrhosis assessment; it is a cardiac marker used to assess for myocardial infarction.
E) Serum lipase is not typically evaluated in cirrhosis assessment; it is a pancreatic enzyme used to diagnose pancreatitis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today